Health Plan Operations
Expert articles and analysis related to health plan operations.
AI Summary ā Last 30 Days
CMS and HHS oversight pressure on Medicare Advantage utilization management is intensifying, with OIG finding that the three largest MA organizations denied prior authorization for long-term acute care and inpatient rehab at some of the highest rates in 2024āreinforcing a structural shift toward tighter scrutiny of post-acute care access, denial reversals, and plan/provider contracting leverage (OIG findings). For VBC stakeholders, the operational risk is moving from āmanage utilizationā to āprove appropriatenessā: ACOs, hospitals, SNFs, IRFs, and home-based care providers will need stronger documentation, data-sharing, and appeal workflows as MA plans defend margins through prior auth and narrower post-acute networks. At the same time, the Trump administrationās proposed Medicaid state-directed payment restrictions and CMS enrollment freezes in hospice and home health signal a broader federal push to constrain supplemental payments and provider growth channels, raising strategic pressure on health systems and risk-bearing entities to reassess Medicaid managed care economics, post-acute capacity, and partnership models (Medicaid payment proposal).
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